MNT Exam 1 Chapter 6 Documentation of the NCP Questions with Correct Answers
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Course
NCP
Institution
NCP
Medical record - Answer-Systematic recording of a patient's care, a location in which all data relating to the problem that brought the patient in for medical are are collected.
American Medical Information Association (AMIA) - Answer-Develops medical information to support patient care, teachin...
MNT Exam 1 Chapter 6 Documentation
of the NCP Questions with Correct
Answers
Medical record - Answer-Systematic recording of a patient's care, a location in which all
data relating to the problem that brought the patient in for medical are are collected.
American Medical Information Association (AMIA) - Answer-Develops medical
information to support patient care, teaching, research, and health care administration.
The Joint Commission - Answer-Website for the national accrediting agency for all
health care facilities in the U.S.
Medical Chart - Answer-Represents ongoing conversations among the different
members of the medical team working on an individual patient's care. The basis for
determining patient care, for documenting communication among health professionals
dedicated to that individual patient's care, and for keeping a clear and comprehensive
record of all that is done for the patient for legal reasons.
Accrediting agencies, Continuous quality improvement programs, Governmental
policies, and Insurance reimbursement - Answer-The driving forces that impact medical
record keeping:
Current Procedural Terminology (CPT) Codes - Answer-In order for a health care
provider to receive payment, the patient's medical record at discharge must contain
documentation of _______ and indicate that the patient received the appropriate care.
Prospective payment system - Answer-Clear, concise wording in the medical record,
using terminology consistent with the ________ will facilitate reimbursement for
services.
Trained medical coders - Answer-Responsible for assigning codes for diagnosis and
treatment so that reimbursement occurs.
Audit and monitor - Answer-Medical record charts are used to ____ and ____ the health
care provided by an institution or specific group of health care providers.
Electronic Medical Record (EMR) - Answer-An application environment composed of
the clinical data repository, clinical decisions support, controlled medical vocabulary,
order entry, computerized provider order entry, pharmacy, and clinical documentation
applications.
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